Embed Size (px)
DESCRIPTION
This file contains discussion covering the diseases of the ears
Citation preview
COLEGIO DE DAGUPAN
COLLEGE OF NURSING
ARELLANO STREET, DAGUPAN CITY
NCM 104- MEDICAL AND SURGICAL NURSING
DISORDERS OF THE EAR
A. Risk factors related to ear disorders
Aging process
Infection
Medications
Ototoxicity
Trauma
Tumors
B. Conductive hearing loss
1. Description
a. Conductive hearing loss occurs when sound waves are
blocked to the inner ear fibers because of external or middle
ear disorders.
b. Disorders often can be corrected with no damage to hearing
or minimal permanent hearing loss.
2. Causes
a. Any inflammatory process or obstruction of the external or
middle ear
b. Tumors
c. Otosclerosis
d. A buildup of scar tissue on the ossicles from previous middle
ear surgery
C. Sensorineural hearing loss
1. Description
a. Sensorineural hearing loss is a pathological process of the
inner ear or of the sensory fibers that lead to the cerebral
cortex.
b. Sensorineural hearing loss is often permanent, and
measures must be taken to reduce further damage or to
attempt to amplify sound as a means of improving hearing to
some degree.
2. Causes
a. Damage to the inner ear structures
b. Damage to the eighth cranial nerve
c. Prolonged exposure to loud noise
d. Medications
e. Trauma
f. Inherited disorders
g. Metabolic and circulatory disorders
h. Infections
i. Surgery
j. Menière's syndrome
k. Diabetes mellitus
l. Myxedema
D. Mixed hearing loss
1. Mixed hearing loss also is known as conductive-sensorineural
hearing loss.
2. Client has sensorineural and conductive hearing loss.
E. Signs of hearing loss and facilitating communication (below)
Signs of Hearing Loss
Frequently asking others to repeat statements
Straining to hear
Turning head or leaning forward to favor one ear
Shouting in conversation
Ringing in the ears
Failing to respond when not looking in the direction of the sound
Answering questions incorrectly
Raising the volume of the television or radio
Avoiding large groups
Better understanding of speech when in small groups
Withdrawing from social interactions
Facilitation of Communication
Using written words if the client is able to see, read, and write
Providing plentyof light in the room
Getting the attention of the client before beginning to speak
Facing the client when speaking
Talking in a room without distracting noises
Moving close to the client and speaking slowly and clearly
Keeping hands and other objects away from the mouth when talking to
the client
Talking in normal volume and at a lower pitch because shouting is not
helpful and higher frequencies are less easily heard
Rephrasing sentences and repeating information
Validating with the client the understanding of statements made by
asking the client to repeat what was said
Reading lips
Encouraging the client to wear glasses when talking to someone to
improve vision for lip reading
Using sign language, which combines speech with hand movements that
signify letters, words, or phrases
Using telephone amplifiers
Flashing lights that are activated by ringing of the telephone or doorbell
Specially trained dogs that help the client be aware of sound and alert the
client to potential danger
F. Cochlear implantation
1. Cochlear implants are used for sensorineural hearing loss.
2. A small computer converts sound waves into electrical impulses.
3. Electrodes are placed by the internal ear with a computer device
attached to the external ear.
4. Electronic impulses directly stimulate nerve fibers.
G. Hearing aids
1. Hearing aids are used for the client with conductive hearing
Loss.
2. Hearing aids can help the client with sensorineural hearing
loss, although they are not as effective.
3. A difficulty that exists in the use of hearing aids is the
amplification of background noise and voices.
4. Client Education Regarding a Hearing Aid
Encourage the client to begin using the hearing aid slowly to adjust to
the device.
Adjust the volume to the minimal hearing level to prevent feedback
squeaking.
Teach the client to concentrate on the sounds that are to be heard and to
filter out background noise.
Instruct the client to clean the ear mold with mild soap and water.
Avoid excessive wetting of the hearing aid and try to keep the hearing
aid dry.
Clean the ear cannula of the hearing aid with a toothpick or pipe cleaner.
Turn off the hearing aid and remove the battery when not in use.
Keep extra batteries on hand.
Keep the hearing aid in a safe place.
Prevent hair sprays, oils, or other hair and face products from coming
into contact with the receiver of the hearing aid.
H. Presbycusis
1. Description
a. Presbycusis is a sensorineural hearing loss associated
with aging.
b. Presbycusis leads to degeneration or atrophy of the
ganglion cells in the cochlea and a loss of elasticity of the
basilar membranes.
c. Presbycusis leads to compromise of the vascular supply
to the inner ear, with changes in several areas of the ear
structure.
2. Assessment
a. Hearing loss is gradual and bilateral.
b. Client states that he or she has no problem with hearing
but cannot understand what the words are.
c. Client thinks that the speaker is mumbling.
I. External otitis
1. Description
a. External otitis is an infective inflammatory or allergic
response involving the structure of the external auditory
canal or auricles.
b. An irritating or infective agent comesinto contact with the
epithelial layer of the external ear.
c. Contact leads to an allergic response or signs and symptoms
of an infection.
d. The skin becomes red, swollen, and tender to touch on
movement.
e. The extensive swelling of the canal can lead to conductive
hearing loss because of obstruction.
f. External otitis is more common in children; it is termed
swimmer's ear and occurs more often in hot, humid
environments.
g. Prevention includes the elimination of irritating or infecting
agents.
2. Assessment
a. Pain
b. Itching
c. Plugged feeling in the ear
d. Redness and edema
e. Exudate
f. Hearing loss
3. Interventions
a. Apply heat locally for 20 minutes three times a day.
b. Encourage rest to assist in reducing pain.
c. Administer antibiotics or corticosteroids as prescribed.
d. Administer analgesics such as aspirin or acetaminophen
(Tylenol) for the pain as prescribed.
e. Instruct the client that the ears should be kept clean and dry.
f. Instruct the client to use earplugs for swimming.
g. Instruct the client that cotton-tipped applicators should not be
used in dry ears because their use can lead to trauma to the
canal.
h. Instruct the client that irritating agents such as hair products
or headphones should be discontinued.
J. Otitis media
A. Description
1. Otitis media is an inflammatory disorder usually caused by an infection
of the middle ear occurring as a result of a blocked eustachian tube,
which prevents normal drainage.
2. Otitis media is a common complication of an acute respiratory infection.
3. Infants and children are more prone to otitis media because their
eustachian tubes are shorter, wider, and straighter.
B. Assessment
1. Fever
2. Irritability and restlessness
3. Loss of appetite
4. Rolling of head from side to side
5. Pulling on or rubbing the ear
6. Earache or pain
7. Signs of hearing loss
8. Purulent ear drainage
9. Red, opaque, bulging, or retracting tympanic membrane
C. Interventions
1. Encourage fluid intake.
2. Teach the parents to feed infants in upright position, to prevent reflux.
3. Instruct the child to avoid chewing as much as possible during the
acute period because chewing increases pain.
4. Provide local heat and have the child lie with the affected ear down.
5. Instruct the parents in the appropriate procedure to clean drainage
from the ear with sterile cotton swabs.
6. Instruct the parents in the administration of analgesics or antipyretics
such as acetaminophen (Tylenol) to decrease fever and pain.
7. Instruct the parents in the administration of the prescribed antibiotics,
emphasizing that the 10- to 14-day period is necessary to eradicate
infective organisms.
8. Instruct the parents that screening for hearing loss may be necessary.
9. Instruct the parents about the procedure for administering ear
medications.
Administration of Medications
In a child younger than age 3, pull the lobe down and back.
In a child older than 3 years, pull the pinna up and back.
D. Myringotomy
1. Description:
Insertion of tympanoplasty tubes into the middle ear to
equalize pressure and keep the ear aerated.
2. Postoperative interventions
b. The client should wear earplugs while bathing, shampooing, and
swimming,
c. Diving and submerging under water are not allowed.
d. Instruct the parents that if the tubes fall out, it is not an emergency,
but the physician should be notified.
e. Parents can administer an analgesic such as acetaminophen
(Tylenol) to relieve discomfort following insertion of
tympanoplasty tubes.
f. Parents should be taught that the child should not blow his or her
nose for 7 to 10 days after surgery.
Client Education Following Myringotomy
Avoid strenuous activities.
Avoid rapid head movements, bouncing, or bending.
Avoid straining on bowel movement.
Avoid drinking through a straw.
Avoid traveling by air.
Avoid forceful coughing.
Avoid contact with persons with colds.
Avoid washing hair, showering, or getting the head wet for 1 week as
prescribed.
Instruct the client that if he or she needs to blow the nose, to blow one
side at a time with the mouth open.
Instruct the client to keep ears dry by keeping a ball of cotton coated
with petroleum jelly in the ear and to change the cotton ball daily.
Instruct the client to report excessive ear drainage to the physician.
K. Chronic otitis media
1. Description
a. Chronic otitis media is a chronic infective, inflammatory,
or allergic response involving the structure of the middle
ear.
b. Surgical treatment is necessary to restore hearing.
c. The type of surgery can vary; it includes a simple
reconstruction of the tympanic membrane, a
myringoplasty, or replacement of the ossicles within the
middle ear.
d. A tympanoplasty, reconstruction of the middle ear, may
be attempted to improve conductive hearing loss.
2. Preoperative interventions
a. Administer antibiotic drops as prescribed.
b. Clean the ear of debris as prescribed; irrigate the ear with
a solution of equal parts of vinegar and sterile water as
prescribed to restore the normal pH of the ear.
c. Instruct the client to avoid persons with upper respiratory
infections.
d. Instruct the client to obtain adequate rest, eat a balanced
diet, and drink adequate fluids.
e. Instruct the client in deep breathing and coughing;
forceful coughing, which increases pressure in the middle
ear, is to be avoided postoperatively.
3. Postoperativeinterventions
a. Inform the client that initial hearing after surgery is
diminished because of the packing in the ear canal;
hearing improvement will occur after the ear canal
packing is removed.
b. Keep the dressing clean and dry.
c. Keep the client flat, with the operative ear up for at least
12 hours.
d. Administer antibiotics as prescribed.
e. Instruct the client that he or she may return to work in
about 3 weeks postoperatively as prescribed.
L. Mastoiditis
1. Description
a. Mastoiditis may be acute or chronic and results from
untreated or inadequately treated chronic or acute otitis
media.
b. The pain is not relieved by myringotomy.
2. Assessment
a. Swelling behind the ear and pain with minimal
movement of the head
b. Cellulitis on the skin or external scalp over the mastoid
process
c. A reddened, dull, thick, immobile tympanic membrane,
with or without perforation
d. Tender and enlarged postauricular lymph nodes
e. Low-grade fever
f. Malaise
g. Anorexia
3. Interventions
a. Prepare the client for surgical removal of infected
material.
b. Monitor for complications.
c. Simple or modified radical mastoidectomy with
tympanoplasty is the most common treatment.
d. Once tissue that is infected is removed, the
tympanoplasty is performed to reconstruct the ossicles
and tympanic membranes in an attempt to restore normal
hearing.
4. Complications
a. Damage to the abducens and facial cranial nerves
b. Damage is exhibited by inability to look laterally (cranial
nerve VI, abducens) and a drooping of the mouth on the
affected side (cranial nerve VII, facial).
c. Meningitis
d. Brain abscess
e. Chronic purulent otitis media
f. Wound infections
g. Vertigo, if the infection spreads into the labyrinth
5. Postoperative interventions
a. Monitor for dizziness.
b. Monitor for signs of meningitis, as evidenced by a stiff
neck and vomiting.
c. Prepare for a wound dressing change 24 hours
postoperatively.
d. Monitor the surgical incision for edema, drainage, and
redness.
e. Position the client flat with the operative side up.
f. Restrict the client to bed with bedside commode
privileges for 24 hours as prescribed.
g. Assist the client with getting out of bed to prevent falling
or injuries from dizziness.
h. With reconstruction of the ossicles via a graft, take
precautions to prevent dislodging of the graft.
M. Otosclerosis
1. Description
a. Otosclerosis is a disease of the labyrinthine capsule of the
middle ear that results in a bony overgrowth of the tissue
surrounding the ossicles.
b. Otosclerosis causes the developmentof irregular areas of
new bone formation and causes the fixation of the bones.
c. Stapes fixation leads to a conductive hearing loss.
d. If the disease involves the inner ear, sensorineural hearing
loss is present.
e. To have bilateral involvement is not uncommon, although
hearing loss may be worse in one ear.
f. The cause is unknown, although it is thought to have a
familial tendency.
g. Nonsurgical intervention promotes the improvement of
hearing through amplification.
h. Surgical intervention involves removal of the bony growth
causing the hearing loss.
i. A partial stapedectomy or complete stapedectomy with
prosthesis (fenestration) may be performed surgically.
2. Assessment
a. Slowly progressing conductive hearing loss
b. Bilateral hearing loss
c. A ringing or roaring type of constant tinnitus
d. Loud sounds heard in the ear when chewing
e. Pinkish discoloration (Schwartze's sign) of the tympanic
membrane, which indicates vascular changes within the ear.
f. Negative Rinne test
g. Weber's test shows lateralization of sound to the ear with the
most conductive hearing loss.
N. Fenestration
1. Description
a. Fenestration is removal of the stapes, with a small hole
drilled in the footplate; a prosthesis is connected between
the incus and footplate.
b. Sounds cause the prosthesis to vibrate in the same
manner as the stapes.
c. Complications include complete hearing loss, prolonged
vertigo, infection, or facial nerve damage.
2. Preoperative interventions
a. Instruct the client in measures to prevent middle ear or
external ear infections.
b. Instruct the client to avoid excessive nose blowing.
c. Instruct the client not to clean the ear canal with
cotton-tipped applicators and to avoid trauma or injury to
the ear canal.
3. Postoperative interventions
a. Inform the client that hearing is initially worse after the
surgical procedure because of swelling and that no
noticeable improvement in hearing may occur for as long
as 6 weeks.
b. Inform the client that the Gelfoam ear packing interferes
with hearing but is used to decrease bleeding.
c. Assist with ambulating during the first 1 to 2 days after
surgery.
d. Provide side rails when the client is in bed.
e. Administer antibiotic, antivertiginous, and pain
medications as prescribed.
f. Assess for facial nerve damage, weakness, changes in
tactile sensation and taste sensation, vertigo, nausea, and
vomiting.
g. Instruct the client to move the head slowly when
changing positions to prevent vertigo.
h. Instruct the client to avoid persons with upper respiratory
tract infections.
i. Instruct the client to avoid showering and getting the
head and wound wet.
j. Instruct the client to avoid using small objects
(cotton-tipped applicators) to clean the external ear canal.
k. Instruct the client to avoid rapid extreme changes in
pressure caused by quick head movements, sneezing,
nose blowing, straining, and changes in altitude.
l. Instruct the client to avoid changes in middle ear pressure
because they could dislodge the graft or prosthesis.
O. Labyrinthitis
1. Description: Infection of the labyrinth that occurs as a complication
of acute or chronic otitis media
2. May result from growth of a cholesteatoma—benign overgrowth of
squamous cell epithelium
3. Assessment
a. Hearing loss that may be permanent on the affected side
b. Tinnitus
c. Spontaneous nystagmus to the affected side
d. Vertigo
e. Nausea and vomiting
4. Interventions
a. Monitor for signs of meningitis, the most common
complication, as evidenced by headache, stiff neck, and
lethargy.
b. Administer systemic antibiotics as prescribed.
c. Advise the client to rest in bed in a darkened room.
d. Administer antiemetics and antivertiginous medications as
prescribed.
e. Instruct the client that the vertigo subsides as the
inflammation resolves.
f. Instruct the client that balance problems that persist may
require gait training through physical therapy.
P. Menière's syndrome
1. Description
a. Menière's syndrome is also called endolymphatic
hydrops; it refers to dilation of the endolymphatic system
by overproduction or decreased reabsorption of
endolymphatic fluid.
b. The syndrome is characterized by tinnitus, unilateral
sensorineural hearing loss, and vertigo.
c. Symptoms occur in attacks and last for several days, and
the client becomes totally incapacitated during the attacks.
d. Initial hearing loss is reversible but as the frequency of
attacks continues, hearing loss becomes permanent.
e. Repeated damage to the cochlea caused by increased
fluid pressure leads to permanent hearing loss.
2. Causes
a. Any factor that increases endolymphatic secretion in the
labyrinth
b. Viral and bacterial infections
c. Allergic reactions
d. Biochemical disturbances
e. Vascular disturbance, producing changes in the
microcirculation in the labyrinth
f. Long-term stress may be a contributing factor.
3. Assessment
a. Feelings of fullness in the ear
b. Tinnitus, as a continuous low-pitched roar or humming
sound, that is present much of the time but worsens just
before and during severe attacks
c. Hearing loss that is worse during an attack
d. Vertigo, as periods of whirling, that might cause the
client to fall to the ground
e. Vertigo that is so intense that even while lying down, the
client holds the bed or ground in an attempt to prevent
the whirling
f. Nausea and vomiting
g. Nystagmus
h. Severe headaches
4. Nonsurgical interventions
a. Prevent injury during vertigo attacks.
b. Provide bed rest in a quiet environment.
c. Provide assistance with walking.
d. Instruct the client to move the head slowly toprevent
worsening of the vertigo.
e. Initiate sodium and fluid restrictions as prescribed.
f. Instruct the client to stop smoking.
g. Administer nicotinic acid (niacin) as prescribed for its
vasodilatory effect.
h. Administer antihistamines as prescribed to reduce the
production of histamine and the inflammation.
i. Administer antiemetics as prescribed.
j. Administer tranquilizers and sedatives as prescribed to
calm the client, allow the client to rest, and control
vertigo, nausea, and vomiting.
k. Mild diuretics may be prescribed to decrease endolymph
volume
5. Surgical interventions
a. Surgery is performed when medical therapy is ineffective
and the functional level of the client has decreased
significantly.
b. Endolymphatic drainage and insertion of a shunt may be
performed early in the course of the disease to assist with
the drainage of excess fluids.
c. A resection of the vestibular nerve or total removal of the
labyrinth or a labyrinthectomy may be performed.
6. Postoperative interventions
a. Assess packing and dressing on the ear.
b. Speak to the client on the side of the unaffected ear.
c. Perform neurological assessments.
d. Maintain side rails.
e. Assist with ambulating.
f. Encourage the client to use a bedside commode rather
than ambulating to the bathroom.
g. Administer antivertiginous and antiemetic medications as
prescribed.
Q. Acoustic neuroma
1. Description
a. Acoustic neuroma is a benign tumor of the vestibular or
acoustic nerve.
b. The tumor may cause damage to hearing and to facial
movements and sensations.
c. Treatment includes surgical removal of the tumor via
craniotomy.
d. Care is taken to preserve the function of the facial nerve.
e. The tumor rarely recurs after surgical removal.
f. Postoperative nursing care is similar to postoperative
craniotomy care.
2. Assessment
a. Symptoms usually begin with tinnitus and progress to
gradual sensorineural hearing loss.
b. As the tumor enlarges, damage to adjacent cranial nerves
occurs.
R. Trauma
1. Description
a. The tympanic membrane has a limited stretching ability
and gives way under high pressure.
b. Foreign objects placed in the external canal may exert
pressure on the tympanic membrane and cause
perforation.
c. If the object continues through the canal, the bony
structure of the stapes, incus, and malleus may be
damaged.
d. A blunt injury to the basal skull and ear can damage the
middle ear structures through fractures extending to the
middle ear.
e. Excessive nose blowing and rapid changes of pressure
that occur with nonpressurized air flights can increase
pressure in the middle ear.
f. Depending on the damage to the ossicles, hearing loss
may or may not return.
2. Interventions
a. Tympanic membrane perforations usually heal within 24
hours.
b. Surgical reconstruction of the ossicles and tympanic
membrane through tympanoplasty or myringoplasty may
be performed to improve hearing.
S. Cerumen and foreign bodies
1. Description
a. Cerumen, or wax, is the most common cause of impacted
canals.
b. Foreign bodies can include vegetables, beads, pencil
erasers, insects, and other objects.
2. Assessment
a. Sensation of fullness in the ear with or without hearing
loss
b. Pain, itching, or bleeding
3. Cerumen
a. Removal of wax by irrigation is a slow process.
b. Irrigation is contraindicated in clients with a history of
tympanic membrane perforation or otitis media.
c. To soften cerumen, add three drops of glycerin or
mineral oil to the ear at bedtime, and three drops of
hydrogen peroxide twice daily as prescribed.
d. After several days, irrigate the ear.
e. The maximum amount of solution that should be
used for irrigation is 50 to 70 mL.
4. Foreign bodies
a. With a foreign object of vegetable matter, irrigation is
used with care because this material expands with
hydration.
b. Insects are killed before removal, unless they can be
coaxed out by flashlight or a humming noise.
c. Mineral oil or diluted alcohol is instilled to suffocate the
insect, which then is removed using ear forceps.
d. Use a small ear forceps to remove the object and avoid
pushing the object farther into the canal and damaging
the tympanic membrane. b. Foreign bodies can include vegetables, beads, pencil
erasers, insects, and other objects.
2. Assessment
a. Sensation of fullness in the ear with or without hearing
loss
b. Pain, itching, or bleeding
3. Cerumen
a. Removal of wax by irrigation is a slow process.
b. Irrigation is contraindicated in clients with a history of
tympanic membrane perforation or otitis media.
c. To soften cerumen, add three drops of glycerin or
mineral oil to the ear at bedtime, and three drops of
hydrogen peroxide twice daily as prescribed.
d. After several days, irrigate the ear.
e. The maximum amount of solution that should be
used for irrigation is 50 to 70 mL.
4. Foreign bodies
a. With a foreign object of vegetable matter, irrigation is
used with care because this material expands with
hydration.
b. Insects are killed before removal, unless they can be
coaxed out by flashlight or a humming noise.
c. Mineral oil or diluted alcohol is instilled to suffocate the
insect, which then is removed using ear forceps.
d. Use a small ear forceps to remove the object and avoid
pushing the object farther into the canal and damaging
the tympanic membrane.
Prepared by:
Christopher R. Bañez, RN, RM, US-RN, MSNc
Jobelle Briones, RN, US-RN, MANc
Alain Jason A. Generale, RN, MANc
Marc Daryl Sarmiento, RN, MANc
Nursing Instructors
Reviewed and Approved by:
Dr. Aida D. Soriano
Dean, College of Nursing
